Emergency Medicine Back To Basics© 2014 Dr. Stanley F. Malamed! All Rights Reserved Medical Emergencies Treatment Occurrence Tooth extraction 38.9% Pulp extirpation 26.9% Unknown

© 2013 Dr. Stanley F. Malamed!All Rights Reserved

Emergency Medicine -

Back To Basics

Stanley F. Malamed, D.D.S.!Dentist Anesthesiologist!

Emeritus Professor of Dentistry!Ostrow School of Dentistry of U.S.C.



Stanley F. Malamed, DDSDentist Anesthesiologist

Emeritus Professor of Dentistry Ostrow School of Dentistry of U.S.C.

Los Angeles, CA, USA


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!

!

I am a paid consultant to:!!

Healthfirst Corporation !!

DISCLOSURE


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[email protected] © 2014 Dr. Stanley F. Malamed!All Rights Reserved

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Medical emergencies CAN and DO

happen in the practice of

dentistry © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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PREPARATION !for!

EMERGENCIES


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Syncope 15,407 (50.3%)Mild allergy 2,583 (8.4%)

Angina Pectoris 2,552 (8.3%)Postural hypotension 2,475 (8.1%)

Seizure 1,595 (5.2%)Asthmatic attack 1,392 (4.5%)Hyperventilation 1,326 (4.3%)Epinephrine Rxn 913 (3.0%)

Hypoglycemia 890 (2.9%) © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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Cardiac Arrest 331 (1.1%)

Anaphylaxis 304 (1.0%)

Myocardial Infarction 289 (0.9%)

L.A. Overdose 204 (0.7%)


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Stage of TreatmentMedical Emergencies

Treatment Stage Occurrence

Immediately before Tx 1.5%

During or after local 54.9%

During treatment 22%After treatment 15.2%

After leaves office 5.5% © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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Medical Emergencies

Treatment OccurrenceTooth extraction 38.9%Pulp extirpation 26.9%

Unknown 12.3%Other treatment 9%

Preparation 7.3%Filling 2.3%

Incision 1.7%

Treatment being performed


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Keep the victim alive until: ! Recovery occurs or !

Help arrives to take over management

LEGAL / MORAL obligation of Healthcare Providers in emergency management


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1. Basic Life Support training!2. Preparation of Dental Office Staff Members!3. Emergency Assistance!4. Emergency Drugs & Equipment

Preparation of the Office & Staff


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BASIC LIFE SUPPORT (CPR, Resuscitation, Reanimation)

is THE single-most important step in the

management of ALL medical emergencies


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The HEART is a PUMP


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© 2014 Dr. Stanley F. Malamed!All Rights Reserved © 2013 Dr. Stanley F. Malamed!

All Rights Reserved

What happens when the heart stops PUMPING blood?


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All Rights Reserved

Blood pressure falls to zero!

Pulse is not palpable!

Consciousness is lost!

Respirations cease


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All Rights Reserved

UNCONSCIOUS

NO BREATHING

NO PULSE

DEAD

DEAD


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All Rights Reserved

Sudden Cardiac Arrest

In the absence of any treatment!death is a certainty


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All Rights Reserved

Doing ‘something’ gives the victim a chance at survival



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At the moment the heart stops pumping, circulation of blood ceases.!

The victim ‘looks’ dead!

They are “CLINICALLY” DEAD!

Clinical death may be reversable © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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The goal of resuscitation is to prevent the PERMANENT death of the victim.!

Cells in the victims body will die when they use up all of the O2 available to them!

BIOLOGICAL or CELLULAR death occurs!

Biological death is irreversible © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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The time between the occurrence of !

CLINICAL and BIOLOGICAL DEATH represents the period

in which RESUSCITATION !may be successful


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American Heart Association 2010 BLS changes


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AHA Guidelines relate primarily to Sudden Cardiac Arrest - fortunately a rare event in the dental environment.!

Cardiac arrest occurs when the heart stops PUMPING blood, not - as some believe - when the heart stops BEATING.


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Sternum

Heart

Spinal column


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P - C - A - B - D!EMERGENCY MANAGEMENT ALGORITHM

Algorithm for ALL

emergency management © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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At any given moment in your cardiovascular system:!

65% of blood is in the venous circulation !

5% of blood is in capillaries!

30% of blood is arterial


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!

Chest compressions of adequate rate and depth, ! Allowing complete chest recoil after each compression,! Minimizing interruptions in compressions, and ! Avoiding excessive ventilation.

Continued emphasis has been placed on high-quality CPR:


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So, Why the change in the algorithm?!

At the moment the heart stops pumping circulation of blood ceases!

the 5% of blood found in capillaries will keep cells alive for a few minutes, depending upon that cells metabolic rate

P - C - A - B - D


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At the moment when blood flow ceases (cardiac arrest occurs) cells still have O2 available (5% capillaries) and will remain alive until they use it up - then cellular death occurs.!

Cells with lower metabolic rates will survive longer!

Cells with higher metabolic rates will die faster

Preventing Biological Death


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Neurons deprived of O2 (anoxia) for approximately 3 minutes will demonstrate degrees of permanent damage

Preventing Biological Death


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Arteries deliver oxygenated blood to capillaries.!

30% of blood volume is found in arteries!

The new algorithm implies “Use up the O2 in the arterial blood which is ‘sitting’ just a short distance away from capillaries before we ventilate.”

P - C - A - B - D


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BASIC LIFE SUPPORT (CPR, Resuscitation, Reanimation)

is THE single-most important step in the

management of ALL medical emergencies


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© 2014 Dr. Stanley F. Malamed!All Rights Reserved��34

Member #1 !•1st person on scene of emergency!

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Stay with victim; yell for ‘HELP’! Administer BLS, as needed


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The DOCTOR!•Need NOT be the person ‘rescuing’ the victim.!

!

Duties CAN be delegated, however . . .! the doctor is ultimately responsible for the actions of staff members


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Member #2, on hearing call for HELP . . .!

!

Obtains: !•1. Emergency drug kit; !•2. Portable O2 cylinder; and !•3. AED !

•. . . bringing them to site of emergency! © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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Members #3, #4 and on . . .!Assigned ancillary tasks such as:!!

Monitoring vital signs (BP, heart rate & rhythm)! Assist with basic life support! Activate EMS! Hold elevator in lobby while awaiting arrival of EMS! Prepare emergency drugs for administration.! Keep written time line record during emergency


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TEAM Approach - Hospital


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!

!

Laminated cards for each member of the TEAM!

Listing duties during emergency

Idea


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EMS ServicesWhen the DOCTOR !

or other!PERSON IN

CHARGE!feels it is necessary

NEVER HESITATE to seek help if you

feel it is needed

When? © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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9 1 1

EMS


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Numerous specialty organizations (AAP, AAOMS, AAPD, AGD) have developed Guidelines for their members and other dentists practicing that specialty!

Emergency drugs & equipment!USA


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IF the doctor utilizes:!!

GENERAL ANESTHESIA!PARENTERAL SEDATION (IM, IV, IN)!ORAL SEDATIONIndividual States have Regulations requiring a predetermined list of EMERGENCY DRUGS & EQUIPMENT

Emergency drugs & equipment!USA


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Advantage: Convenience; Drug updatesDisadvantage: Complacency; $ $ $

Proprietary Emergency Kits


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Critical drugs & equipment THE BASIC SEVEN


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Single most important !

drug in emergency medicine

Epinephrine (Adrenaline)


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1:1,000 AND 1:2,000!Autoinjector!1:2,000 up to 30 kg weight!1:1,000 if more than 30 kg!

!

INDICATION: Anaphylaxis! CONTRAINDICATIONS: None

Epinephrine


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Histamine-Blocker

Diphenhydramine HCl injectable!Benadryl!

50 mg/mL!!

INDICATION: Anaphylaxis, Mild Allergy!CONTRAINDICATIONS: None


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Albuterol!Proventil, Ventolin, ProAir!

Bronchospasm (asthma)!

NO CONTRAINDICATIONS!

Spacer recommended for younger patients

Ventolin

Bronchodilator


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Coronary artery VASODILATORNitroglycerin!

Nitrolingual spray (USD$200+)!

Nitrostat sublingual tablets (USD$50/100tabs)!

0.4 mg/dose!

INDICATION: Angina pectoris; Prehospital management of cardiac pain!

CONTRAINDICATION:!

Hypotension © 2014 Dr. Stanley F. Malamed!All Rights Reserved

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Non-diet soft drink!

Orange juice!

Tube of concentrated glucose!

InstaGlucose!

!

INDICATION: Hypoglycemia!

CONTRAINDICATION: Unconsciousness

For!oral !

administration

Antihypoglycemic


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Aspirin (ASA)!

325 mg!Powdered or!Chewable!

!

INDICATION: Suspected myocardial infarction!CONTRAINDICATION: Allergy

Thrombolytic


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The 2nd most important drug in emergency medicine

Oxygen


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‘E’ cylinder + delivery system!

!

INDICATION: Any medical emergency!

CONTRAINDICATION: None *

* Hyperventilation

Oxygen


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Disposable face masks (pediatric & adult for ventilation with supplemental O2)

Equipment


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Automated External Defibrillator (ED)

Why YOU want 2 AED’s

Equipment


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70% of out-of-hospital SCA occur in the HOME of the victim.!

As dentists we have TWO homes:!

The one in which we live!

The one in which we work



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Automated External Defibrillator

Defibrillation has been a component of Healthcare Provider Basic Life Support

since 2000!!

Survival from Out-Of-Hospital Sudden Cardiac Arrest is related to the elapsed

time from collapse of the victim to defibrillation


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44 of 50 states in the USA mandate successful BASIC LIFE SUPPORT training to maintain DENTAL LICENSURE!

12 states (as of December 2013) mandate presence of an AED on-site!

Florida, Colorado, Arkansas, Georgia, Louisiana, Massachusetts, Michigan, Maryland, Tennessee, North Carolina, West Virginia, and Wisconsin


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The doctor is expected to be knowledgeable of, and able to

use, any drug or piece of emergency equipment contained

in the emergency kit.

Note


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EMERGENCY MEDICINE

BASIC MANAGEMENT of!MEDICAL EMERGENCIES


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P - C - A - B - D


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Emergency Management

P - Position


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CONSCIOUS !

responds to sensory stimulation (e.g. “shake & shout”)!

blood flow to brain is (minimally) adequate!

!

ANY POSITION the victim desires is appropriate

P - Position


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UNCONSCIOUS !

lack of response to sensory stimulation (e.g. “shake & shout”)!

< blood flow to brain most common cause of unconsciousness!

SUPINE with feet elevated slightly!

increases blood flow to brain!

does NOT compromise breathing © 2014 Dr. Stanley F. Malamed!All Rights Reserved

P - Position

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UNCONSCIOUS !

Lack of response to sensory stimulation (e.g. “shake & shout”)!

Quickly assess for presence of respiratory efforts & circulation!

If NO then immediately start C-A-B sequence!

If YES then continue with A-B © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

P - Position

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C - Circulation


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UNCONSCIOUS !

Palpate peripheral pulse: CAROTID recommended [adult]!

Palpate peripheral pulse: BRACHIAL recommended [child]!

Palpate with index / middle fingers; NOT thumb!

Not more than 10 seconds!

If NO pulse or QUESTIONABLE pulse, begin CHEST COMPRESSION

C - Circulation


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CONSCIOUS !

responds to sensory stimulation (e.g. “shake & shout”)!

blood flow to brain is (minimally) adequate!

peripheral pulse WILL be palpable (e.g. radial, brachial, carotid)!

Assisted circulation (e.g. chest compression) is NOT necessary


C - Circulation

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A - Airway


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CONSCIOUS !

If patient can speak:!

Airway is open, breathing is, at minimum, adequate!

!

Airway management is NOT necessary

A - Airway


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UNCONSCIOUS - breathing & pulse!

Skeletal muscles RELAX with LOC!

Tongue (a large skeletal muscle) falls back into airway!

Tongue is the PRIMARY cause of airway obstruction!

HEAD TILT - CHIN LIFT


A - Airway

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B - Breathing


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CONSCIOUS !

If patient can speak:!

Airway is open, breathing is, at minimum, adequate!

!

Ventilation is NOT necessary

B - Breathing


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UNCONSCIOUS - respiratory efforts & pulse!

“Look, Listen, Feel” = No longer recommended by AHA!

Quick evaluation of breathing.


B - Breathing

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UNCONSCIOUS - Respiratory efforts & pulse!

See chest rise does NOT mean patient is breathing!

Breathing is exchange of air!

Chest rise means victim is TRYING to breath!

Airway may be obstructed (tongue, foreign body) and chest will still rise.


B - Breathing

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UNCONSCIOUS - Pulse, no respiratory efforts!

In absence of spontaneous respiratory efforts (e.g. chest not rising), ventilation is necessary:!

!

2 full ventilations, seeing chest rise with each!

Maintain head tilt - chin lift!

Seal nose © 2014 Dr. Stanley F. Malamed!All Rights Reserved

B - Breathing

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P - C - A - B!Keep the victim alive

Ensuring that the victim’s BRAIN is receiving an !adequate supply of blood that contains OXYGEN


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D - Definitive Care


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Diagnosis!Drugs!Defibrillation

D - Definitive Care


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Management of Specific Medical Emergencies

Altered Consciousness!Respiratory Distress!

Drug-Related Emergencies!Chest ‘Pain’


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Altered Consciousness


EMERGENCY MEDICINE © 2014 Dr. Stanley F. Malamed!All Rights Reserved

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Deprivation of blood, O2 or sugar produces!alterations in CNS functioning:!

Altered consciousness!Unconsciousness

The brain requires a constant supply of blood containing both

oxygen and glucose in order to function properly


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Percentages of Cardiac Output Distributed to Different Organ Systems

Region % of CO receivedKidney 22

GI system, Spleen 21Skeletal Muscle 15

Brain 14Skin 6Liver 6Bone 5

Myocardium 3Other 8

Adapted from Mohrman DE, Heller LJ. Cardiovascular physiology, ed 7, New York 2010. Lange Medical Books/McGraw Hill © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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!

!

Brain:!!

2% of body weight!!

14% of cardiac output

!

!

Muscle:!!

50% of body weight!!

15% of cardiac output © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

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Hypoglycemia

Hyperglycemia


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Hyperglycemia!Hypoglycemia

Diabetes mellitusMost likely candidate for HYPOGLYCEMIA = Type 1 Diabetic


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Type 1 Type 2

Less common!Juvenile onset!

Severe!Insulin - all

More common!Adult onset!

Mild!Insulin - 20% - 30%


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Will NOT be an acute medical emergency

in the dental office environment

Hyperglycemia


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2nd leading cause of loss of consciousness! 1st is HYPOTENSION (low blood pressure)!

Decreased O2! Decreased ‘sugar’

Hypoglycemia


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Can happen to anyone but . . .! Most likely to occur in a type 1 diabetic!

IDDM! ‘Juvenile onset’

Hypoglycemia


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Causes of HYPOGLYCEMIA in diabetic patients

66%

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Determine if . . .!!

Patient has eaten recently! Taken insulin recently! Consider administering “sugar”

Hypoglycemia


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Cold (moist skin)!Sweating (diaphoresis)!

Tremor (shaking)!Mentally disoriented (< CNS)

Classic S&S

Hypoglycemia


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P . . .!

C . . .!

A . . .!

B . . .!

D . . .

ConsciousHypoglycemia


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Administer ‘sugar”!

Glucose gel !

Fruit juices!

Orange preferred by many!

Hard candy!

Soft drinks [non-diet]

Hypoglycemia


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Decreasing blood glucose levels

~ 50

~ 30 - 20

< 20

Hypoglycemia


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P . . .!

C . . .!

A . . .!

B . . .!

D . . .

Hypoglycemia - unconscious


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P . . . Supine!

To increase blood flow to brain!

C . . . Pulse present, BP ‘normal’ !

A . . . Head tilt - chin lift necessary!

B . . . Spontaneous ventilation present



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P, C, A, B . . . Victim remains unconscious in spite of adequate blood flow to brain & O2.!

At this juncture we have ruled out:!

Syncope (fainting) and!

Cardiac arrest



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P, C, A, B . . . Victim remains unconscious in spite of adequate blood flow to brain + oxygen.!

Do we know what the cause of LOC is?!

If NO . . . activate EMS!



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P, C, A, B . . . Victim remains unconscious in spite of adequate blood flow to brain + oxygen.!

Do we know what the cause of LOC is?!

If YES, but cannot treat . . . activate EMS!



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P . . .!C . . .!A . . .!B . . .!D . . . Activate EMS (9.1.1)



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P . . .!C . . .!A . . .!B . . .!D . . . Do not put anything that

might liquefy in the mouth of an unconscious patient



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Definitive management:!!

50% or 25% Dextrose [30 ml] IV! 1 mg glucagon IV or IM

Hypoglycemia


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ALTERED CONSCIOUSNESSSeizures


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Convulsion, ‘Fit’

Definition:!A paroxysmal episode, caused by

abnormal electrical conduction in the brain, resulting in the abrupt onset of

transient neurologic symptoms such as involuntary muscle movements, sensory disturbances and altered consciousness.

Also called convulsion.

Seizure


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Damaged cellsWhat happens to cells when they are DEAD?!

NOTHING - they are dead

SCAB


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Damaged cells

What happens to cells when they are DAMAGED?

Damaged


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Damaged cells

Ingrown nail = an ‘OWIE’!Bronchi = BRONCHOSPASM!Myocardium = DYSRHYTHMIAS!

When cells are damaged, hypoxic or anoxic, they become hyperexcitable


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!

Brain (CNS) = SEIZURES!!


Damaged cells


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Epileptic patients !

Stress induces seizures!

Cerebral hypoxia !

Syncope + inadequate airway!

Hypoglycemia!

Local anesthetic overdose

Causes of seizures in the dental environment


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Seizures - Dialogue history What type of seizure(s) do you have?! What anticonvulsant medications do you take?!

Grand Mal - French for ‘Great Illness”


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What type of seizure do you have?! What anticonvulsant medications do you take?! How well controlled are your seizures?! What is your aura? !

Generalized tonic-clonic

Seizures - Dialogue history

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An epileptic aura precedes an epileptic seizure and may involve visual disturbances, dizziness, numbness, or any of a number of sensations which the patient may find difficult to describe exactly.

Epileptic AURA

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In epilepsy the aura serves a useful purpose in that it warns of an impending attack and gives the patient time to seek privacy and a safe place to lie down before the seizure actually begins.

Epileptic AURA

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Seizure management


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Remove any/all items of dental equipment from the patients mouth!

!

Prepare the patient for the seizure:!Remain in dental chair!Loosen tight clothing

Seizure management


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Are self-limiting! (most) SEIZURES STOP! Last not more than 2 to 5 minutes! Do NOT require anticonvulsant therapy! Do NOT result in injury

Generalized tonic clonic seizure!GTCS, ‘Grand Mal’


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In a generalized tonic clonic seizure . . .!During the *ictal* phase:!!

CNS stimulation! Respiratory stimulation! Cardiovascular stimulation

BadOK

So-So



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Ictal refers to a physiologic state or event such as a seizure. The word originates from the Latin ictus, meaning a blow or a stroke. In electroencephalography (EEG), the recording during an actual seizure is said to be "ictal". There are four ictal states which include pre-ictal, ictal, post-ictal, and inter-ictal. Pre-ictal refers to the state immediately before the actual seizure, stroke, or headache, though it's recently come to light that some of characteristics of this stage (such as visual auras) are actually the beginnings of the ictal state. Post-ictal refers to the state shortly after the event. Inter-ictal refers to the period between seizures, or convulsions.


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In a generalized tonic clonic seizure . . .!During the *ictal* phase:!!

CNS stimulation! Respiratory stimulation! Cardiovascular stimulation

BadOK

So-So



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P . . .!C . . .!A . . .!B . . .!D . . .



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Chair is narrow! Victim may fall from chair! Keep victim in the dental chair

Seizure management - TONIC


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Protect victim from injury:!Rescuer 1: arms . . .gently!!Rescuer 2: legs . . . gently!!

Rescuer 3: airway!remove “pillow” or “donut”

from headrest of chair!↓!

Summon EMS ?????

Seizure management - CLONIC


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DO NOT PUT ANYTHING INTO THE MOUTH OF A CONVULSING PERSON


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In a generalized tonic clonic seizure . . .! During the *post-ictal* phase:!!

CNS depression! Respiratory depression! Cardiovascular depression

BadBad

Bad

Seizure management


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The postictal state is the altered state of consciousness that a person enters after experiencing a seizure. It usually lasts between 5 and 30 minutes, but sometimes longer in the case of larger or more severe seizures and is characterized by drowsiness, confusion, nausea, hypertension, headache or migraine and other disorienting symptoms. Additionally, emergence from this period is often accompanied by amnesia or other memory defects. It is during this period that the brain recovers from the trauma of the seizure.


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P . . .!C . . .!A . . .!B . . .!D . . .

Reassess:Post-ictal phase


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CAB as needed! Airway, if snoring! Breathing, circulation - usually not necessary!

Patient is disoriented, sleeping! Position: turn on side, if at all possible!

Minimizes risk of aspiration of vomitus ! Aids in airway maintenance, !

Dental chair: turn on side, if at all possible! If not: Supine & maintain airway prn

Post-ictal phase


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Determine disposition of patient following seizure:!

Hospitalization, if not oriented to space & time:!

Where are you?! What day is it?!

Discharge home in company of companion if oriented to space and time!

Management of status epilepticus

Why consider EMS?


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Status epilepticus is defined as:!!

A medical emergency characterized by continuous seizures lasting more than 30 minutes without interruption. Status epilepticus can be precipitated by the sudden withdrawal of anticonvulsant drugs, inadequate body levels of glucose, a brain tumor, a head injury, a high fever, or poisoning.

GTCS (Grand mal) status

Mosby's Medical Dictionary, 8th edition. © 2009, Elsevier.!

R U really going to wait 30 minutes?

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Terminate dental procedure! Position patient! Activate EMS! Protect patient from injury! BLS, prn! Administer oxygen! Monitor vital signs

Management of Grand Mal Status


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Venipuncture (adult or larger child [> 30 kg]) ! Anticonvulsant drug - titrated to effect IV! Administer 50% dextrose!!

Definitive management:! Stabilize & transport to hospital ED

EMS


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Smaller pediatric patient (< 30 kg)! Anticonvulsant drug - 0.2 mg/kg IN! Administer 25% dextrose!!

Definitive management:! Stabilize & transport to hospital ED

EMS


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Administer anticonvulsants:! Administered IV or IN! IV benzodiazepines:!

Midazolam!

GTCS (Grand mal) status


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�140

Lack of response to sensory stimulation

Unconsciousness


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Drop in blood pressure!Lack of blood/oxygen . . . syncope!Lack of sugar . . . hypoglycemia!Postural hypotension!

Seizures! CNS depressant overdose! Local anesthetic overdose! Cardiac arrest! Anaphylaxis! Cerebrovascular accident!

!

EtiologiesUnconsciousness


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Vasodepressor syncope, Vasovagal syncope, Common faint

Syncope


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‘Fight or flight’ response to stress:! > blood flow to arms + legs!

If patient moves:! Muscle contraction! Blood returns to heart! Cerebral blood flow maintained!

If patient remains still:! Decreased blood return to heart! Decreased cardiac output

Presyncope


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Decreased cardiac output!!

Decreased blood pressure (hypotension)!!

Decreased cerebral circulation:!Diminished CNS functioning!

S&S of ‘feeling faint’

Presyncope


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!

Decreased BP and cerebral blood flow lead to . . .!!

Reflex increase in heart rate [tachycardia] resulting in . . .!

!

Transient maintenance of adequate blood pressure! Low, but near baseline

Presyncope


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Presyncope - S&S


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Position patient supine! Increase blood pressure! Maintain cerebral circulation!

Administer O2!

Administer aromatic ammonia! Stimulates movement . . .! Increases return of blood to heart - IF supine

Presyncope Management


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Presyncope Management


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Dental treatment may continue . . . !

IF both the doctor and patient !

are comfortable.!

Determine reason for episode and manage

Presyncope


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!151

Healthy young children!DO NOT

faint


151

In the pediatric dental environment

it is the parent!(usually the father)!

who is most likely to faint


152

In the absence of treatment! Decompensation [fatigue] occurs:!

Severe bradycardia develops! HR between 0 and 20 (Periods of asystole)!

Blood pressure & cerebral blood flow diminish! Consciousness is lost

Vasodepressor syncope, Vasovagal syncope, Common faint

Syncope


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In the presence of continued cerebral hypoxia . . . anoxia!

Muscle twitching to GTCS may develop!!

Prevented or terminated by:! Positioning! Airway maintenance

Syncope


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P . . .!A . . .!B . . .!C . . .!D . . .

Syncope


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P . . . Position! Supine with feet elevated 10-15 degrees!

C . . . Assess, compress chest . . . not necessary!A . . . Assess, maintain usually necessary!

Oxygen, prn!B . . . Assess, ventilate . .. usually not necessary!

Syncope management


156

Manage symptomatically:! Oxygen! Cool compress!

Permit recovery!Determine cause of episode!

Consider future Tx modifications!Discharge in custody of responsible adult

Following the return of consciousnessSyncope management


157

Respiratory Distress

EMERGENCY MEDICINE © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

158

HYPERVENTILATION


159

Hyperventilation

An anxiety-induced situation in which the victim loses control over their breathing.


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Hyperventilation

The hyperventilating person is breathing:!(1) extremely rapidly [tachypnea]!(2) either shallow or deep


161

In the pediatric dental environment, hyperventilation will almost always

be a manifestation of ACUTE ANXIETY

Hyperventilation


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S&S of hyperventilation are produced by the LOSS of CO2 from the blood leading to HYPOCAPNEA.!!

Hyperventilation


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HYPERVENTILATION!Clinical manifestations


164

Goals of treatment of hyperventilation:!!

(1) Calm patient!(2) Decrease respiratory rate!(3) Elevate CO2 level!

Hyperventilation


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The TREATMENT of HYPERVENTILATION!

is found at the !END OF ONES ARMS!

Victim cups their hands over their mouth & nose, !rebreathing exhaled air, which contains high levels of CO2

Hyperventilation


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Victim cups their hands over their mouth & nose, !rebreathing exhaled air,

which contains high levels of CO2

Inhaled air = 0.03% CO2!Exhaled air = 3.97% CO2

Hyperventilation


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In the absence of adequate treatment!CARPOPEDAL TETANY !

may develop!

Hyperventilation


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�169

P . . .!C . . .!A . . .!B . . .!D . . .

Hyperventilation


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Asthma!Hyperactive Airway Disease

Bronchospasm


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Damaged cells

!

Bronchi = BRONCHOSPASM!!

When cells are damaged, hypoxic or anoxic, they become

hyperexcitable


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Asthmatic Triggers


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What kind of asthma do you have?!

Allergic . . . non-allergic! !

Allergic: What precipitates an acute episode?!

Aspirin!

NSAID’s!

Exercise-induced asthma!

(bi)Sulfites!

Vasopressor-containing local anesthetics

Asthma


173

In the pediatric dental environment, bronchospasm !

will almost always be a manifestation of ACUTE ANXIETY

Bronchospasm


174

What drug[s] do you use for an acute episode?!Your ‘Rescue Drug’!!

Beta agonists, such as:! Albuterol [Pro-Air, Proventil, Ventolin]! Metaproterenol [Alupent]

Asthma


175

What drug[s] do you use to minimize/prevent acute episodes?!

!

Inhaled steroids (triamcinolone - Azmacort)! Long-acting beta agonist (salmeterol – Serevent)!

Asthma


176

Have you ever been hospitalized for your asthma?!!

Status asthmaticus! Bronchospasm that is refractory (resistant) to

2 doses of the ‘rescue drug’ (bronchodilator)

Asthma


177

Remind patient to bring their "rescue drug" with them to dental office!

!

!

!

Treatment of asthma:! Inhaled steroids . . . to prevent acute episodes! Bronchodilator . . . to treat acute episodes

Asthma


178

Feeling of chest congestion!Cough: c/s sputum production!

Wheezing!Dyspnea!

Patient sits up!Use of accessory muscles of respiration!

Increased anxiety!Tachypnea

Signs & symptoms !of acute bronchospasm


179

��180

P . . .!C . . .!A . . .!B . . .!D . . .

Bronchospasm


180

!181

Administer bronchodilator . . .!episode terminates!

!

Subsequent dental care!!

Discharge of patient

Bronchospasm management


181

!182

Summon EMS . . . if!!

patient requests!or!

episode is refractory to !2 doses of bronchodilator

Bronchospasm Management


182

Status asthmaticus is an acute exacerbation of asthma that

remains unresponsive to initial treatment with bronchodilators.

Status Asthmaticus


183

If bronchospasm is not relieved, or! If doctor is uncomfortable, or! If parent or child wishes,! ACTIVATE EMS STAT

Status Asthmaticus


184


185

If EMS delayed, or!If situation deteriorates . . .!!

IM epinephrine q5m!Vastus lateralis!0.3 mg or 0.15 mg of 1:1000

15 - 30 kg = 0.15 mg!>30 kg = 0.3 mg

Status Asthmaticus


186

Vastus Lateralis

Epinephrine 1:1,000

Vastus lateralis


187

Drug-Related Emergencies

EMERGENCY MEDICINE © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

188


Systemic adverse drug reactions

The TWO systemic adverse reactions that ALL drugs can produce are:!

ALLERGY!

OVERDOSE (toxic reaction)

189


Drug OVERDOSE IS dose-related:!

You have to give enough to produce a high blood level!

ALLERGY is NOT dose-related:!

Allergy is an over-reaction to a foreign substance (allergen) by the immune system

Overdose v. Allergy!Dosage

190


OVERDOSE:!

S&S are related to NORMAL pharmacology of drug!

S&S will VARY depending upon drug producing OD!

ETOH . . . CNS depression (excessive depression)!

Cocaine . . . CNS, CVS stimulation (excessive stimulation)!

ALLERGY:!

S&S are ALWAYS the same regardless of etiology.!

Itching, hives, rash, bronchospasm, vasodilation!

Overdose v. Allergy!Signs & Symptoms

191


Allergy

DRUG RELATED EMERGENCIES

192


Allergy represents an OVERREACTION by the bodies immune system to a foreign substance (allergen)

Allergy

193


Allergic ReactionsDiagnosis!

&!Management

194


Allergen!

Mast cells & Basophils!

!

!

Histamine Leukotrienes

ECF – Anaphylaxis Kallikreins

Prostaglandins

Allergic Reactions

S&S of allergy

195


DISTRIBUTION:!

Everywhere, but higher amounts in lungs, skin and GI!

Rapidly stored in mast cells and basophils

HistamineThe Primary Mediator of the Allergic Reaction!

196


RELEASE CONDITIONS:!

Type 1 hypersensitivity (allergy)!

Tissue injury!

Drugs & other foreign compounds, e.g. meperidine (Demerol)


197


Heart rate = increases!

Blood pressure = decreases!

Small blood vessels = dilate!

Flushing!

Increased capillary permeability


198


Itching . . . Pruritis!

Hives . . . Urticaria!

Rash . . . Erythema!

Bronchospasm!

Vasodilation

HistaminePharmacology! - Summary

199


Possible predictors of severity of the reaction

Rapidity of ONSET! of signs and symptoms!

!

PROGRESSION! of signs and symptoms

Allergic Reactions

200


Delayed:!

S & S develop slowly [>60 min]!

Reaction involves skin!

Immediate:!

S & S develop within minutes of exposure!

Reaction involves respiratory a/o cardiovascular systems

Onset of S&S

201


Usual: Starts as SKIN - does not progress!

Stimulation of EXOCRINE GLANDS e.g. tearing, nasal discharge (runny nose)!

Spasm of intestinal smooth muscle (e.g. cramping)!

Bronchospasm!

Vasodilation of blood vessels

Progression of S&S

202


P . . .!

C . . .!

A . . .!

B . . .!

D . . .

Delayed onset skin reaction

S&S!> 1 hour after antigenic exposure

203


Allergic Skin Reaction

204


Management:!D . . . !Parenteral histamine blockers:! Diphenhydramine . . . IM (vastus lateralis)! 50 mg adults! 25 mg (< 30 kg)

Delayed Onset Skin Reaction

205


Management:!D . . . !Oral histamine blockers:! Diphenhydramine!

50 mg qid adults! 25 mg qid < 30 kg! For 3 days

Delayed Onset Skin Reaction

206


ANAPHYLAXIS

207


Anaphylaxis Common etiologies

Stinging insects Penicillin Latex

Peanuts Aspirin, NSAIDs Shellfish

208


Anaphylaxis

!

Respiratory compromise and cardiovascular collapse cause most deaths!

Time to CV collapse: Food (25-35 min); Insect sting (10-15 min)

Definition: An acute and potentially life-threatening multi-system allergic reaction

209

© 2014 Dr. Stanley F. Malamed!All Rights Reserved16 January 2008

210


P . . . Based upon primary complaint:!

“Can’t breathe” . . . upright!

“Feel faint” . . . supine, feet elevated!

C . . . prn!

A . . . prn!

B . . . prn

Anaphylaxis . . . Management

211


The diagnosis and management of anaphylaxis practice parameter:

2010 Update!Lieberman P, Nicklas RA, Oppenheimer J, et al!

Allerg Clin Immunol 126:477-480, 2010

212


The more rapidly anaphylaxis develops, the more likely the reaction is

to be severe and potentially life-threatening

The diagnosis and management of anaphylaxis practice parameter: 2010 Update. Lieberman P, Nicklas RA, Oppenheimer J, et al


213


!

!

Prompt recognition of signs and symptoms of anaphylaxis is crucial. !

If there is any doubt, it is generally better to administer

epinephrine



214


Epinephrine and oxygen are the most important therapeutic agents administered in anaphylaxis.!

Epinephrine is the drug of choice, and the appropriate dose should be administered promptly at the onset of apparent anaphylaxis



215


There is no absolute contraindication

to epinephrine administration in

anaphylaxis



216


D . . . Definitive care!

Epinephrine!

As soon as possible!

Every 5 minutes until!

Victim recovers!

Help (9.1.1) arrives


217


D . . . Definitive care!

Epinephrine!

Basic life support, as needed!

Oxygen!

EMS (9.1.1)


218


0.3 mg/dose = adult!0.15 mg/dose = child (15 - 30 kg)


219


“E” cylinder !portable delivery

system

OXYGEN

220


Anaphylaxis: How do patients die?Vasodilation!Increased vascular permeability may shift 35% - 50% of intravascular volume to the extravascular space within 10 minutes

221


Assess C, A, B’s!

Epinephrine 0.3 - 0.5 mg of 1:1,000 IM thigh (adult); 0.15 mg of 1:1,000 IM thigh (child). Give quickly and repeat every 5 - 15 minutes as needed!

Classically, adult dose is given to children >30 kg, but may also give to 25 kg!

Give as soon as possible

Anaphylaxis . . . Management (1)

222


Position supine, feet elevated. This position is equivalent to infusion 1 - 2 liters in the central vascular compartment


(1)

223


!

Diphenhydramine: 25-50 mg IV (adults); 1 mg/kg children (up to 50 mg)!

Prednisone 0.5 mg/kg/day orally - will have NO ACUTE EFFECT


224


Oxygen - for patients with prolonged reactions, are short of breath, experiencing chest pain!Call 9.1.1. prn


225


According to the 2010 practice parameter update on anaphylaxis, measures to take in order of importance:!

Epinephrine!

Patient position!

Oxygen!

IV fluids!

Nebulized therapy!

Vasopressors!

Antihistamines, steroids & other agents

226


Epinephrine in Anaphylaxis

There are NO absolute contraindictions to using epinephrine in anaphylaxis!

Up to 23% of patients with anaphylaxis who receive epinephrine are reported to receive a 2nd dose because of ongoing S&S or a biphasic reaction

227


Epinephrine - Thigh or DeltoidIM injection in the thigh has been shown to provide more rapid absorption and higher plasma levels in asymptomatic patients.!

Not studied in patients with active anaphylaxis!

Obese patients - IM injection in thigh may be unrealistic. NO data that SC or IM dose in the deltoid fails in anaphylaxis

228


Vastus lateralis = Thigh

229


Epinephrine - Alternative routes

Alternative routes for epinephrine injection such as SC, sublingual or inhalation are NOT recommended because they do not achieve the necessary high, rapid plasma concentrations.

230


Why epinephrine?Reverses 2 components of anaphylaxis

which lead to death:! Bronchospasm . . . Epi is bronchodilator! Hypotension . . . Epi is vasopressor!

Epi, through its vasoconstrictive actions can reverse edema, but only if administered PROMPTLY!

!

Works fast! IM vastus lateralis w/I ± 2 minutes

231


Goal: short-term survival! !

Keep the victim alive until! They recover! Help arrives on scene!


232


Goal: short-term survival! !

Epi . . . Epi . . . Epi! BLS, prn! Oxygen! EMS!


233


Recovery:! Relief of bronchospasm! Elevation of blood pressure!


234


Recovery:! Epinephrine:!

Rapid onset - GOOD! Short duration - BAD!


235


!

!

!

Histamine blocker IM (1 mL)! Diphenhydramine HCl 50 mg !

25 mg - up to 30 kg!

Once life is out of danger . . .


236


Histamine blockers IV!!

Corticosteroids IV ! Decadron, Solu-Cortef, Solu-Medrol! Slow onset, long duration! Stabilize cell membranes!

Prevent edema, vasodilation!


237


Hospitalization! ED . . . several hours - observation! Hospitalized . . . overnight - observation! Hospitalized . . . several days


238


Represents the only emergency situation which requires the immediate administration of a drug, epinephrine, in order for the victim to have a chance of survival.!

The more rapidly epinephrine is administered at onset of anaphylaxis the greater the chance of survival!

Absent epinephrine, survival from anaphylaxis is less likely

Anaphylaxis

239


Since allergy has the potential to be life-threatening . . .

!

How can a doctor prevent an allergic reaction?

240


When confronted with ‘alleged’ allergy:!

ALWAYS BELIEVE THE PATIENT!

Do NOT administer or prescribe the drug in question until all doubt has been erased from the mind of both the doctor and the patient

Alleged allergy

241


(1) Describe your ‘allergic’ reaction:!

TRUE allergy: ‘Itching, hives & a rash’, bronchospasm (wheezing), Drop in BP (hypotension)!

NOT allergy: dizzy, lightheaded, faint, shaking, palpitations

Alleged LA allergy What to ask your patient?

242


(2) How was your ‘allergic’ reaction managed:!

TRUE allergy: Epinephrine, Histamine-blocker (diphenhydramine [Benadryl]), Corticosteroid!

NOT allergy: Nothing (it got better), Oxygen, “Smelling salts” (aromatic ammonia vaporole)

Alleged LA allergy What to ask your patient?

243


. . . Cannot always be prevented.!!

. . . May occur even with prior history of no adverse response to a drug.!

!

. . . Must always be prepared for.

Allergy

244


Chest ‘Pain’

Chest ‘Pain’


245

Heart muscle - MYOCARDIUM contracts, squeezing blood out of the heart into the pulmonary artery (right side of heart) or

aorta (left side of heart)!

To continue to function the myocardium requires its own blood supply!

Myocardial blood supply is from CORONARY ARTERIES


246


CORONARY ARTERIES

247


Plaque

PlaquePlaque

Coronary Artery Disease


248



The deposition, over time, of a lipid-rich plaque (LDL) within the walls of coronary arteries

249



When the workload of the heart increases (e.g. stress = pain, fear), myocardium needs an increased blood flow which

cannot be met by narrowed coronary artery

250


Myocardium not receiving an adequate blood supply becomes ischemic, leading to the onset of anginal ‘pain’

Transient Myocardial Ischemia = Angina Pectoris

251


Angina Pectoris

With rest or administration of nitroglycerin the myocardial workload decreases and the chest ‘pain’ dissipates

252

��253

Angina pectoris and dentistry

The only time ANGINA should be considered as a diagnosis in acute chest pain is where the patient (victim) has a PREEXISTING HISTORY of ANGINA


253

In anginal patient when:!!

‘Pain’ worse than usual! 3 doses of nitroglycerin fail to relieve discomfort!

doses every 5 minutes! Nitroglycerin relieves ‘pain’, but ‘pain’ returns.

Consider myocardial infarction when:


254


ALWAYS ! when there is no prior history

of cardiovascular disease!

!

Consider myocardial infarction:

255

Prolonged Myocardial Ischemia

RUPTURE of the PLAQUE into the lumen of the coronary artery terminates blood flow to an area of myocardium


256

Prolonged myocardial ischemia leads to damage and then death (infarction) of myocardium © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

257


Acute Coronary Syndrome

Angina Pectoris

Acute Myocardial InfarctionNarrowed

Obstructed

258

��259

P . . .!C . . .!A . . .!B . . .!D . . .

First Time Chest ‘Pain”


259


ALWAYS ! when there is no prior

history of cardiovascular disease!

Consider Myocardial Infarction:

260

Acute Myocardial Infarction


261


P . . . Position C . . . Circulation A . . . Airway B . . . Breathing D . . . Definitive care MONA

Acute myocardial infarction

262


Acronym for the PRE-HOSPITAL MANAGEMENT OF A SUSPECTED MYOCARDIAL INFARCTION

MONA

263


D . . . Definitive care !“Greet the ambulance at

the door to the emergency department with MONA”

MONA

264


!

Morphine!

Oxygen!

Nitroglycerin!

AspirinPrehospital management of suspected MI

MONA

265


P . . . Position C . . . Circulation A . . . Airway B . . . Breathing D . . . Definitive care MONA = NONA


266


Morphine!

MONA

Prehospital management of suspected MI

!

N2O-O2!

Oxygen!

Nitroglycerin!

Aspirin

NONA=

=

267


!268

Nitrous Oxide - Oxygen 50% - 50%

As analgesic as IV morphine!Separates pain from suffering!

Sedative!Relaxes scared patient!

50% O2!2.5 times ambient air


268


!269

Aspirin in Myocardial Infarction

325 mg. chewed, swallowed - POWDERED, if available! 20 minute onset!

Prevents blood clot (thrombosis) from increasing in size! Increases chances of primary balloon angioplasty being successful


269


270



271



272

SILENT MI!!

Women (up to 50%)! Elderly! Diabetics!!

Do not present with classic signs & symptoms



273

Myocardium = DYSRHYTHMIAS!




274


Arrhythmia or DysrhythmiaArrhythmia: A = ‘not‘ or ‘‘without’ Therefore, an arrhythmia implies NO beat or a ‘flat line’. !

The only true arrhythmia is asystole (no contraction)!

Dysrhythmia: Dys = abnormal ‘An abnormal cardiac rhythm’

275



Normal Sinus Rhythm - NSR


276


Premature Ventricular Complexes Monomorphic (Unifocal)

ALL PVC’s look alike

Area of ischemic myocardium

277


Premature Ventricular Complexes Polymorphic (Multifocal)

PVC’s vary in size & shape

MORE CLINICALLY SIGNIFICANT!

278

Patient is CONSCIOUS!8 of 11 contractions (systoles) are normal, ejecting blood into the systemic circulation.!!

Output of blood is 73% of normal

Premature Ventricular Contractions!PVC’s


279

Patient is CONSCIOUS!yet demonstrating S&S of decreased blood flow to periphery:!

Cyanotic mucous membranes!Ashen gray skin color!Diaphoresis!Generalized feeling of fatigue

Premature Ventricular Contractions!PVC’s


280


Premature Ventricular Contractions!Bigeminy

Cardiac output = 50% © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

281

The dentist’s objective in a medical emergency situation

Keep the victim alive until: !(1) Recovery occurs or !(2) Help arrives to take over management


282

So, what exactly has been done prior to EMS arrival to PREVENT the occurrence of cardiac arrest?

Morphine (N2O-O2)!Oxygen!

Nitroglycerin!Aspirin


283

NOTHING !Ischemic myocardiam still exists;!Dysrhythmias still occurring;!But the pump - though damaged - is still pumping

We have been LUCKY © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

284

!285

!

Most OOH-SCA are related to acute dysrhythmias (VF/ pulseless VT)!

!

Most occur during the !

1st hour !after symptom onset!

!

52% of MI mortality

pre-hospital 24 hrs, in-hospital 48 hrs, in-hospital 30 days

5219

218

Deaths from MI


Cardiac Arrest


285

!286

Getting into the ‘system’!(9.1.1)!

is THE most important thing!

that can be done for the!victim of a ‘suspected

heart attack’ (AMI)

52%

Acute myocardial infarction

Cardiac Arrest

Within!1st hour © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

286

Cardiac Arrest


287

CARDIAC ARREST occurs when the heart ceases to

PUMP BLOOD

In CARDIAC ARREST the heart, usually, is still

BEATING It is no longer PUMPING


288

CARDIAC ARREST occurs when the heart ceases to

PUMP BLOOD

There are four rhythms that constitute cardiac arrest

(1) (pulseless) Ventricular Tachycardia (2) Ventricular Fibrillation (coarse & fine) (3) Asystole (4) Pulseless Electrical Activity (PEA)


289


Pulseless Ventricular Tachycardia!

!

Ventricular Fibrillation!

!

Asystole!

!

Pulseless Electrical Activity

Cardiac Arrest

290

Ventricular Tachycardia!VT!

VT with a pulse or pulseless VT

The ischemic area of myocardium has taken control. ALL beats are PVCs


291

Ventricular Tachycardia!VT!

VT with a pulse or pulseless VT

VT is an organized rhythm (all beats similar) Extremely rapid ventricular rate (~180 bpm)


292

Ventricular Tachycardia

Coarse Ventricular Fibrillation

VT degenerates into a CHAOTIC, unorganized

quivering of the myocardium - VENTRICULAR FIBRILLATION


293


Common clinical findings!

Disappearance of pulse with VF!

Collapse, unconsciousness!

Agonal breaths apnea in < 5 minutes!

Onset of reversible death!

Ventricular Fibrillation

294


Coarse Ventricular Fibrillation

Then, as the myocardium continues to weaken . . . © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

295

Electrical activity lessens

Fine Ventricular Fibrillation


296

CARDIAC ARREST

Ventricular Tachycardia Ventricular Fibrillation!coarse & fine

Shockable rhythms


297

NOT A SHOCKABLE RHYTHM

Asystolic Cardiac Arrest


298


What happens when the heart stops PUMPING blood?

299


Blood pressure falls to zero,!

Pulse isn not palpable,!

Consciousness is lost, and!

Respirations cease.!

And the victim is . . .

300


UNCONSCIOUS

NOT BREATHING

NO PULSE

DEAD

DEAD

301


What is the difference between ‘Heart Attack’ and Sudden Cardiac Arrest?

‘Dead’ Alive

302

UNCONSCIOUS

NO PULSE

Clinical Death

Cardiac Arrest

NOT BREATHING


303

UNCONSCIOUS

NOT BREATHING

NO PULSE

Cardiac Arrest

The victim ‘looks’ dead © 2014 Dr. Stanley F. Malamed!All Rights Reserved

304

At the moment of clinical death the heart stops pumping circulation of blood ceases:!

!

65% of blood is in the venous circulation !

5% of blood is in capillaries!

30% of blood is arterial © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

305

Our goal in resuscitation is to prevent the PERMANENT death of the victim.!

Cells in the victims body will die when they use up all of the O2 available to them!

CELLULAR or BIOLOGICAL death occurs!

Biological death is irreversible © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

306

The time between the occurrence of !

CLINICAL and BIOLOGICAL DEATH represents the period

in which RESUSCITATION !may be successful


307

Brain cells (neurons) have a high metabolic rate.!

!

!

!

!

A degree of permanent neurologic deficit can be expected when neurons are

deprived of O2 for 3 or more minutes.

Surviving Sudden Cardiac Arrest


308

Death . . . or . . .

No BLS Delayed EMS, Delayed BLS & Defibrillation:


309

Begin brain damage

Global Neurological Damage

Severe brain damage

No BLS Delayed EMS, Delayed BLS & Defibrillation:


310

Basic life support . . . Circulates oxygenated blood . . . Does NOT convert cardiac arrest into a functional rhythm (e.g. NSR)!

BLS simply increases the time during which the myocardium is still alive

A very important fact about CPR (Basic Life Support):


311

Early BLS ↑ duration of VF (fine VF)!

+ delayed defibrillation © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

312

Early BLS ↑ duration of VF (fine VF)!

+ delayed defibrillation!

2% - 8% survival © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

313

~20% survival

Early BLS + early defibrillation (coarse VF)


314

Up to 74% in some situations!Neurological deficit unlikely

Early BLS + very early defibrillation (coarse VF)


315

minutes 2 4 6 8 10

Early CPR Very early

defib. Early ACLS

up to 74% survive

CPR ACLSDefibrillation

Early CPR Early

Defibrillation

20% surviveCPR Defibrillation

No CPR Delayed

Defibrillation 0 - 2% survive

Defibrillation

Early CPR Delayed

Defibrillation2 - 8% survive

CPR Defibrillation

The TIME from COLLAPSE to DEFIBRILLATION

Survival RatesEMS arrival

BYSTANDER-INITIATED BLS © 2014 Dr. Stanley F. Malamed!All Rights Reserved

316

How critical is response time to survival?

For every minute a victim is in cardiac arrest the chance of survival decreases by between 7% and 10%.!

This assumes that BLS is being administered

Survival to hospital discharge


317

How critical is response time to SURVIVAL?

0

20

40

60

80

100

Time to Defibrillation !

(minutes)

1 3 5 7 9

10

30

50

70

90

0 108642

Survival !(percentage)

LV casino . . . 74%! Airports . . . 60%! Seattle WA . . . 46%! Boston MA . . . 40%! San Francisco . . . 9% ! USA average . . . 7.4%! New York City . . . 2%! Los Angeles CA . . . 1.4%! Chicago IL . . . 1%

Airports

Casino Floor Las Vegas

New York City

Seattle, WABoston, MA

USA average

Survival to hospital discharge


318

Basic Life Support - 2010 AHA


319


Automated External Defibrillators(AED’s)

320

Simplistically, an AED is a battery operated computer which is capable of determining whether or not VF/VT is present.!

VF/VT present:! ‘SHOCK ADVISED”

How to use an AED


321

Any rhythm other than VF/VT! PEA, asystole, NSR!

‘NO SHOCK ADVISED’! ‘Check airway’! ‘Check breathing’! ‘Check pulse’! ‘If no pulse, continue CPR’

How to use an AED


322

VF . . . chaotic, uncordinated ‘quivering’ of myocardium !

Coarse VF

How an AED works


323

How an AED works AED delivers a biphasic (2 shocks) shock across the chest - through the

myocardium - depolarizing all myocardial cells at the same time.


324

AED delivers a biphasic (2 shocks) shock across the chest - through the myocardium - depolarizing all myocardial cells at the same time, producing . . .!ASYSTOLE!

© 2012 Dr. Stanley F. Malamed!All Rights ReservedCoarse VF

Defibrillation

Asystole

How an AED works


325

The more ‘alive’ the myocardium when depolarized the more likely it is that the SA node will spontaneously depolarize inducing a normal sinus rhythm.

How an AED works


Asystole


NSR © 2014 Dr. Stanley F. Malamed!

All Rights Reserved

326

REBOOT the

HEART

How an AED works


327


Can the chest be compressed adequately with the victim in the dental chair?

Lepere AJ, Finn J, Jacobs I!Efficacy of cardiopulmonary resuscitation performed in a dental chair!J Australian Dental Association 48(4) 244-247, 2003 (December)

YES328


The very first step in management of all medical emergencies is !

BASIC LIFE SUPPORT, !as needed

Rules to Remember

329


And remember . . . “Stuff Happens” Syncope 15,407 (50.3%)

Mild allergy 2,583 (8.4%)

Angina Pectoris 2,552 (8.3%)

Postural hypotension 2,475 (8.1%)

Seizure 1,595 (5.2%)

Asthmatic attack 1,392 (4.5%)

Hyperventilation 1,326 (4.3%)

Epinephrine Rxn 913 (3.0%)

Hypoglycemia 890 (2.9%)

Cardiac Arrest 331 (1.1%)

Anaphylaxis 304 (1.0%)

Myocardial Infarction 289 (0.9%)

L.A. Overdose 204 (0.7%)

330


Drug therapy is ALWAYS secondary to

basic life support


P . . . position!

C . . . circulation !

A . . . airway!

B . . . breathing!

D . . . definitive care

P . . . position!

C . . . circulation!

A . . . airway!

B . . . breathing!

D . . . defibrillation

Cardiac arrest non-Cardiac arrest

331


P - C - A - B!Keep the victim alive

332


www.healthfirst.comwww.elsevier.com

333


Thank you . . .

and BE PREPARED!


334

Emergency Medicine Back To Basics© 2014 Dr. Stanley F. Malamed! All Rights Reserved Medical Emergencies Treatment Occurrence Tooth extraction 38.9% Pulp extirpation 26.9% Unknown

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